Carotid Endarterectomy for Symptomatic Carotid Stenosis.

Abstract

What are the benefits of carotid endarterectomy for people with symptomatic carotid stenosis?Carotid stenosis is a narrowing of the carotid arteries caused by atherosclerosis, the formation of plaque or fatty deposits on the artery walls.1 The buildup of plaque reduces blood flow to the brain and can lead to an embolus and potentially to an ischemic stroke.2Most patients with carotid stenosis are asymptomatic until the artery becomes severely narrowed or a clot forms. Common first symptoms are related to a transient ischemic attack resulting from a temporary blockage of blood flow to the brain, which subsequently returns to normal. The symptoms are similar to those of stroke and include weakness or numbness on one side of the body, aphasia, facial droop, and diplopia and other vision impairments.3The risk of a stroke resulting from severe carotid stenosis warrants evaluation of all treatment options, with a goal to prevent a stroke from occurring. The World Health Organization lists stroke as the second leading cause of death globally4; more than 13 million people have a stroke each year, and more than 5 million die because of it.5Treatment options for carotid stenosis combine lifestyle changes, medication, and surgical procedures. The most common surgical procedure is carotid endarterectomy, which removes the plaque from the carotid artery with a goal to restore blood flow and prevent a cerebral embolism.1The carotid endarterectomy procedure was first introduced in the 1950s as a stroke-preventing measure; by the early 1980s, more than 100 000 procedures were performed annually. In 1985, a study was published in which investigators stated that the procedure provided no benefit, leading researchers to conduct further studies to assess the efficacy of the procedure.6 As a result, the number of carotid endarterectomies varied each year. The randomized controlled studies that followed regarding the benefit of carotid endarterectomy found different outcomes and used different methods, making it challenging to determine which practices should be recommended.Among these studies was a risk-benefit analysis of carotid endarterectomy related to factors such as the percentage of stenosis (eg, > 60%) and symptoms of transient ischemic attack at presentation. The purpose of this systematic review was to determine the risks and benefits of carotid endarterectomy with appropriate medical management, compared with those of only appropriate medical management, in patients who recently experienced symptomatic carotid stenosis.This summary is an update to a previously published systematic review that was conducted in 2017.7 As new evidence on a topic becomes available, updates are necessary to account for the results that the new evidence presents. This update, conducted by Rerkasem et al,8 included 3 randomized controlled trials comprising 6092 adult participants.The primary outcome was the 5-year cumulative risk for any type of stroke or operative death. The indicator was defined as any stroke or death that occurred within 30 days after carotid endarterectomy.Rerkasem et al8 independently assessed the risk of bias for each study, including selection, performance, detection, attrition, reporting, and publication biases. They resolved any disagreements by reviewing the data together and through discussion.The authors used risk ratios (RRs) with 95% CIs for dichotomous outcomes as measures of treatment effect between the comparisons and outcomes. They used the internationally approved Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to determine the certainty of evidence— high, moderate, low, or very low— for each outcome9: The outcome varied depending on the percentage of carotid stenosis: This systematic review provides guidance related to the risks of carotid endarterectomy that can help inform nurses and other clinicians when they are advocating for the best available care and helping patients understand their options. As always, several factors can determine the outcome of a procedure. With carotid endarterectomy, however, the degree of carotid stenosis is the most important factor to consider. For patients with at least 30% stenosis, the evidence indicates that the procedure would provide benefit. That benefit increased for patients with 70% to 99% stenosis.One of the limitations of this review by Rerkasem et al8 is that the included studies are dated— they had been conducted in the 1990s—as no more recent studies were available that met the inclusion criteria. That being the case, we must consider that during the past 20 years medical treatments have advanced and now help both control atherosclerosis and prevent strokes. As a result, a comparison between the groups studied in this review (only medical treatment vs medical treatment and endarterectomy) would likely not be as significant. Studies are currently underway to explore such a comparison.As nurses caring for critically ill patients, we must advocate for the best evidence-based treatment remaining an important piece of our role. We must always consider the best available evidence and understand the feasibility, appropriateness, meaningfulness, and effectiveness of any intervention to determine whether it is most appropriate to implement in our individual context.